REPUBLIC OF THE PHILIPPINES )

IN ______________________ )S.S

AFFIDAVIT OF LOSS

I YOLANDA T. TAN , Filipino of legal age ,with postal address at # 4 Hontiveros St.
Corner JB Romero St. BF Homes , Brgy Holy Spirit Quezon City , after being duly sworn to in
accordance with law , herby despose and state. :

That , I am a holder of SSS # 33-6532245-0

That despite diligent search and efforts to locate it, I could not find the same, I now
believe that it was lost beyond recovery.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing.

IN WITNESS WHEROF, I have hereunto set my hand this ______ day of

____________2017 in _________, Philippines.

YOLANDA T. TAN
( Signature of Affiant
)

ACKNOWLEDGEMENT

SUBSCRIBED AND TO before me in this _______ day of ______________ 2017.

Doc . No.____________ :
Page No.____________:
Book No.____________:
Series of 2017